Actually, Coloradans were slightly meatier — on average — than Montanans in 2013. Colorado last held the skinniest spot in 2012. But Colorado consistently has had one of the two lowest obesity rates since 2008.

The data are based on survey respondents’ self-reported height and weight. Americans with a body-mass index of 30 or higher are classified as obese.

Nationally, the obesity rate rose to 27.7 percent in 2014, compared with 27.1 percent in 2013 and 25.5 percent in 2008.

Mississippi and West Virginia have had the two highest obesity rates since 2012. And, since Gallup and Healthways began tracking this in 2008, five states have been among the top 10 every year:Louisiana, Arkansas, Virginia, Kentucky, Mississippi and West Virginia.

As far as up and down: Four states had significant increases: Nevada, New Mexico, Alabama and Minnesota. Only one state, Tennessee, enjoyed a statistically significant drop in obesity in 2014.

A sign placed out on the 16th Street Mall beckoned people in late March to sign up for health insurance through the Affordable Care and Connect for Health Colorado. (Kathryn Scott Osler, The Denver Post)

In an early draft of the 2016 Connect for Health Colorado budget, board member and finance committee chair Arnold Salazar saw some potential revenues that could sustain the state health insurance exchange.

“Clearly our fees are too low,” Salazar said at the April 28 joint Finance and Operations committee meeting at the state health insurance exchange.

With user fees of 1.4 percent on health insurance plans adjusted upward, perhaps as high as 3.5 percent to 4.5 percent, Salazar said, it’s a different financial forecast.

“We are well within striking distance of sustainability,” Salazar said. “We want to make sure we have the revenue to make this sustainable.”

Almost $179 million in federal startup grants are running out this year. The exchange will have to run itself with other income and private grants.

Interim CEO Gary Drews, who will stay at the exchange through mid-May to ease the transition to a new interim CEO, Kevin Patterson, said it was too early in the budget process to talk about fee levels. But staff did need guidance as to service level, he said.

Once determinations are made by the board in May on technology and call center fixes and upgrades needed to provide consumers with an optimal level of service, Drews said, the exchange can settle on expenditures and fee structure. Draft annual budget scenarios for the next few years range from $28 million to $55 million.

“In any configuration,” Salazar said, “we’re probably going to have to go to a fee increase, either to 3.5 (percent) or 4.5 percent.”

The federal exchange charges 3.5 percent. Two of the state-based exchanges closest in enrollment size to Colorado’s charge administrative fees of 2.5 percent to 3.5 percent, while two others rely more on a broad market assessment, according to a Connect for Health analysis.

That’s another revenue stream for the Colorado exchange, the special broad market assessment paid by insurance companies on health plan members outside the exchange — $1.25 per insured person per month — could be raised to $1.80. The assessment, which ends in Colorado next year, could be extended by legislation.

“As it relates to anything — as it relates to fees — let’s make sure we’re talking to the customers — the carriers,” said non-voting board member David Padrino, representing the governor’s office. “Let’s engage them in the right way and a really open way to make sure it’s something that works for that customer base.”

Drews said the staff was talking to carriers.

All four states with exchange enrollment numbers closest to Connect for Health’s have draft 2016 budgets between $40 million and $50 million. All four receive from a third to more than half of their revenues in the form of some funding from Medicaid, which gains many enrollees through the exchanges’ online enrollment systems.

Because Connect for Health Colorado was set up as an independent nonprofit with a public mission, rather than as a state agency, it’s unclear if and how much it can recoup from Medicaid, but Drews and staff are looking for reimbursement.

“Are other revenue raisers off the table?” asked new board member Adela Flores-Brennan.

The board previously has considered ancillary products, such as vision insurance, but committee members said the exchange doesn’t have the staff or other resources to launch new products for next year. Another possibility, committee members said, would be advertising on the Connect for Health website.

Republicans on the Senate Business, Labor and Technology Committee Monday defeated a bill with a party-line 5-4 vote that would have protected patients from unexpectedly high, uncovered bills from doctors.

Bill opponents said it would give insurance companies unfair leverage in negotiations with health care providers.

Insurance plans pay differently for health care that is provided in-network vs. what they designate as out-of-network care. Even patients who choose to go to an in-network hospital or clinic to avoid these higher costs are sometimes treated by an unknown out-of-network provider and hit with surprise charges.

Sen. Irene Aguilar, a primary care physician, said she wrote Senate Bill 259 to protect patients against such practices, which critics equate with consumer fraud.

Family physician Robin Dickinson lobbied for the bill because, she said, even she was hit with these unexpected charges although she was knowledgeable about the issues and risks.

Dickinson suffered a tear in an artery in her neck that clotted and sent two clots to her brain causing two strokes, she said.

“I had high-deductible insurance so carefully watched all the bills that came in,” she said in emails to generate support for the bill. “The ER doctor and neurologists, who SAVED MY LIFE, billed a reasonable couple hundred dollars. But the hospitalist, who basically filled out paperwork (I’ve done his exact job numerous times myself and it’s not difficult or time-consuming), billed me $900!”

She said when she called his billing office she learned he was out of network. But it wasn’t her insurance company picking up the tab, she said. It was her responsibility.

“I had no idea that he was out of network, or I would have kicked him out of my room,” Dicksinson said. “I consider this fraud and manipulation.”

Aguilar described the bill’s augmented standards for disclosure as requiring providers to:

“Inform a patient seeking covered services at an in-network facility about legal protections against ‘balance billing.’ Balance billing is defined as billing a person with coverage the difference between what the insurance company pays and what the provider charges.

Inform the covered person that balance billing is possible if treatment comes from an out-of-network provider at an in-network facility.

The out-of-network provider must inform the patient that they are seeking treatment from an out-of-network provider. They must also provide the billing charges or an estimate to the patient on request, in writing.

The out-of-network provider may not ‘balance bill’ the patient, unless the person has agreed to pay the difference in advance.

Insurance carriers must provide written notice to their clients about their out-of-network obligations.

Emergency services are exempt from the bill.”

Yet the bill had some heavy-hitter opposition, including the Colorado Medical Society.

Opponents outlined the issues this way in the legislative alerts they circulated:

“The out-of-network provider, who doesn’t have a contract with the health plan, is required to submit a bill to the person’s health plan and not collect any payment from the patient, beyond deductibles, copayment and coinsurance, and is prohibited from any further balance billing of the patient.

In this March 31, 2014 file photo, Michelle Decker, left, an employee of Connect For Health Colorado, the state’s health insurance exchange, explains options and procedures to a walk in client signing up for insurance on the last day before fines were imposed, in Denver. IT and online enrollment glitches plagued thousands of consumers during 2015 open enrollment.(AP Photo/Brennan Linsley)

The legislative oversight committee for the state health insurance exchange heard Wednesday from brokers, agents and consumers about the good, the bad and the ugly aspects of the two-year-old marketplace.

Even as the oversight committee heard testimony from some of those directly affected by operational problems and successes at the exchange, the Senate passed a bill allowing the committee to change its name and to meet 10 times after the legislative session ends.

The new name will be the Colorado Health Insurance Exchange Oversight Committee – only slightly less of a mouthful than the current Legislative Health Benefit Exchange Implementation Review Committee.

“We’re seeking the unvarnished truth,” said the committee, chair Sen. Ellen Roberts, R-Durango. Roberts has promised greater scrutiny of the exchange by the committee.

Ben Price, director of the Colorado Association of Health Plans, opened by saying the exchange was very important to carriers, who wanted a marketplace where consumers could really compare what was available to them.

“We’re two years in, and it’s been a success, but it hasn’t always been a pretty success,” Price said. “There are still many, many technical challenges. From a carrier’s perspective, we’re at a critical juncture.”

More than 140,000 Coloradans have been insured, he said, and the marketplace here is very competitive – with 12 major carriers while states with comparable populations have only two or three.

Fixes to the exchanges online enrollment system – its Shared Eligibility System with Medicaid – must be done quickly and right to avoid the bottleneck created during the most recent enrollment, Price said.

“It has delayed people’s coverage for months,” he said.

Tammy Niederman with the Colorado State Association of Health Underwriters said brokers provided the exchange with about 40 percent of the business done.

Niederman said that simple changes to people’s policies – such as adding a new baby, changing an address – that were once readily effected are now difficult. And many people were inadvertently terminated.

“The carrier is not getting feeds in a timely manner,” she said. “These are very simple things, right? Things that were once easy to accomplish have now turned into extremely stressful situations (for clients).”

Debra Judy with the Colorado Consumer Health Initiative said the ranks of the uninsured have shrunk, and they have heard many success stories of consumers getting critical coverage at reasonable rates. Yet, she said, the enrollment process must get simpler to use and correct.

All three groups praised hard-working staff at Connect for Health Colorado, but commented that staff size was too small to get the job done.

Christy Mahon, 34, of Denver, became the first woman ever to ski all of Colorado’s 54 fourteeners. Christy is pictured hiking the steep East Face on her way to the top of 14,025 ft Pyramid Peak oon May 8th 2010, the 47th highest mountain peak in Colorado, and 78th highest peak in U.S. It is located in the Elk Mountains in southeastern Pitkin County. Photo by Ted Mahon, Special to the Denver Post

People in Colorado’s mountain communities are living the dream, at least according to a new ranking of counties based on quality of life and length of life.

The 2015 County Health Rankings, a program of the Robert Wood Johnson Foundation released March 25, identify Colorado’s healthiest counties based on factors from tobacco use and exercise to access to high-quality care — using the latest available data.

Pitkin County is ranked first. It is joined at the top 10 by several mountain counties and a couple of plains representatives. Denver County placed a dismal 40th. In the metro area, Douglas and Boulder came out on top, in part because healthy outcomes are tied to income and education levels.

Rural counties in the sate’s southeast rural, less-developed region generally are at the lower end, including Conejos, Las Animas, Costilla and Huerfano counties.

Overall, Colorado compares well with national statistics in areas such as years lost to “premature death” (before age 75) — Coloradans have better longevity — and smoking — 21 percent of U.S adults smoke, compared with 17 percent across Colorado.

However, Coloradans overall have poorer air and drinking water quality compared with national averages, the study says. And Coloradans, on average, are more at risk for violent crime. In the U.S, there are 11.9 incidences per 100,000 population. In Colorado, it’s 12.7 incidences. By county, the violent crime rate varies from 10 incidences to 13.8 per 100,000.

Published online at countyhealthrankings.org, the rankings are meant to help counties understand what influences longevity and well being.

“The rankings are unique in their ability to measure the current overall health of each county in all 50 states. They also look at a variety of measures that affect the future health of communities, such as high school graduation rates, access to healthy foods, rates of smoking, obesity, and teen births.”

The rankings’ creators advise communities use the rankings to find support for local health improvement initiatives among government agencies, healthcare providers, community organizations, business leaders, policy makers and the public.

Medicaid patients enrolling through the state health insurance exchange are taking too much of its time and resources, exchange board members said Monday, but Medicaid officials propose an even tighter partnership with a single technology vendor.

The federal policy of “no wrong door” was meant to be a single online portal for the uninsured that would seamlessly determine their eligibility for either Medicaid or private insurance with tax subsidies. But system and user errors have caused thousands of Colorado customers seeking financial assistance under the Affordable Care Act to get stuck mid-enrollment.

The online Shared Eligibility System — the interface between the state marketplace and Medicaid — has caused most of the intractable problems, exchange officials say.

Although open enrollment for 2015 health plans officially ended Feb. 15, at least 700 people are still hung up in the system — down from a peak of 10,000 complaints, according to Connect for Health Colorado’s enrollment report, released Monday at the exchange board meeting.

Before technology glitches can be fixed, exchange board members said, they must resolve a key policy question about the mission and brand of the state’s independent nonprofit marketplace. How aligned or entangled should it become with the much-larger Medicaid system administered through Colorado Department of Health Care Policy and Financing.

Exchange interim chief executive Gary Drews said the board must decide to “ either take on the face of Medicaid and change our brand,” or find another solution.

“Every day that goes by we’re feeling the pressure of not working on these things,” Drews said. “We do know we have a vast portion of our resources going to Medicaid. (Should we) put people in the hands of folks whose core competencies are Medicaid?”

Discussions between Health Care Policy and Financing and Connect for Health Colorado will be watched by the governor’s office.

“The governor is interested in making sure that there is an appropriate level of collaboration … and that we get the right people talking about this,” said David Padrino, Gov. John Hickenlooper’s deputy chief of staff. He declined to say the governor’s office would mediate any dispute.

Exchange staff estimate that Medicaid customers made 40 percent to 45 percent of calls to the customer service center, for which the forecast 2014-15 budget has climbed from just less than the the $15 million approved by the board to about $21 million.

“The Medicaid expansion has cost us significantly more than we thought,” said board member Dr. Mike Fallon. “We need paying customers to become financially stable. The customers of Connect for Health are paying to support Medicaid. We don’t have the money to do this. Our $26 million dollar (annual operating) budget is now laughable.”

Health Care Policy and Financing executive director Sue Birch said the data the exchange offered on costs attributable to Medicaid enrollees was “primitive.”

“What I don’t think is being heard is that Medicaid will pay its fair share once it gets that (better) data,” said Birch, who is also a non-voting member of the exchange board.

Drews and others said exchange workers don’t have full access to information in the Medicaid system, the Colorado Benefits-Management System, which makes it difficult for the exchange to help households caught between the two systems.

The board voted Monday to seek proposals for an independent end-to-end review of the technology systems, while moving ahead with obvious tech fixes and deciding the larger issue of the exchange’s involvement in Medicaid.

Only 54 percent of 2015 enrollees received financial assistance. The other 46 percent didn’t have to navigate the eligibility system.

One proposed technology fix is that customers who are clearly not Medicaid-eligible get shunted along an expedited pathway toward tax credits, bypassing the shared eligibility system Cost estimates range from $2 million to $7 million.

Another option is an even more integrated system with Medicaid, which Fallon said he opposed.

“We become a small cog in a huge machine we have no control over,” Fallon said. “I encourage the board to do minimum interoperability with Medicaid.”

Of the total 224,171 applications for financial assistance submitted through the Shared Eligibility System during the recent three-month open enrollment period, 76,783 applications originated from Connect for Health Colorado, the exchange reported. An estimated 78 percent of marketplace customers who went through the Shared Eligibility System received a “real-time” (roughly an hour) eligibility determination. About 52,000 were denied Medicaid and were sent to the marketplace eligible for financial subsidies toward their private insurance plans.

Birch said board members were overlooking the “extraordinary successes” of the exchange-Medicaid partnership to date.

“Our reason for existing is to help people who need insurance,” Birch said.

Broker John Luhman said during public comment that he disagreed with the exchange estimates of enrollees still shut out of coverage.

“You’re telling me there are 700 people left out there. I’m telling you you’re wrong,” Luhman said. “I have 38 households hung up.”

Luhman is one of 1,300 brokers working with the exchange.

“I’m afraid of my customers going though this ungodly process over and over,” he said. “You have a system of technology that’s horrible. It stinks.”

Medicaid Administrator Marilyn Tavenner oversaw the rocky rollout of the president’s health care law _ says she’s stepping down at the end of February. In an email to staff at the Centers for Medicare and Medicaid Services, Tavenner says she’s leaving with “sadness and mixed emotions.” (AP Photo/Manuel Balce Ceneta, File)

Under health care reform, Medicare bonuses are going to hospitals that are getting things right, at least from the federal government’s perspective.

In Colorado, where 44 hospitals participated in the program, 57 percent received bonuses, or increased Medicare payments in 2015, while 43 percent will have penalties, or reduced payments. None broke even.

The Medicare incentive program encourages hospitals to earn higher Medicare payments by providing comparatively good care — it assesses providers on 26 different measures, including patient satisfaction, death rates and costliness of care. It also recognizes improvements in care, even if hospital metrics remain below standard.

For determining bonuses added to 2015 payments, Medicare assessed hospitals’ performance compared with other hospitals in the second half of 2012 and all of 2013. It also judged how much they had improved from two years before.

When all the programs are combined, big hospitals with more than 400 beds will receive an average bonus of almost $213,000, compared with an average penalty of $1.2 million, analyst Eric Fontana of the Advisory Board Co., told Kaiser. For small hospitals with 200 or fewer bed, the average bonus in 2015 will be about $32,000, compared with an average penalty of $131,000.

In addition, Medicare also began docking about 200 hospitals for not working fast enough to switch over to electronic medical records.

Combining all the programs, more than 6 percent of Medicare payments now hinge on performance measures, Kaiser Health News says.

Together, these reforms add to one of the biggest changes to Medicare in its 50-year-history, health policy experts say.

More than 1,600 hospitals were exempted from the program, including children’s and veterans hospitals.

Katie Cary, the infection prevention manager, left, tapes Donielle Robertson, the clinical nurse coordinator for the adult emergency room, at Presbyterian/St. Luke’s Medical Center into her gown as they practiced safe procedures in October for “donning and doffing” of the medical protection gear in the event they begin treating Ebola patients at the Denver hospital. (Denver Post Photo by Cyrus McCrimmon)

The Centers for Disease Control and Prevention report that U.S. hospitals, including Colorado’s, have made progress overall since 2008 in the battle to eliminate infections that commonly threaten hospital patients.

Through 2013, the most recent year for which data are available, hospitals nationwide saw a 46 percent decrease in central-line-associated bloodstream infections, according to a CDC report released Jan. 22.

The Healthcare-Associated Infection Progress Report consists of national and state-by-state summaries of healthcare-associated infections.

Colorado’s 52 participating hospitals had a lower composite rate of central-line-associated bloodstream infections in the baseline year, 2008, compared with the national standardized infection ratio. It was not significantly different from the improved national standard in 2013.

The CDC reports an 8 percent decrease nationwide in hospital-onset MRSA bacteremia between 2011 and 2013 and a 10 percent decrease in C. difficile infections between 2011 and 2013.

While Colorado hospitals compared favorably to the national rate in terms of MRSA infections, the state’s facilities were significantly worse than the national standard when comparing C. difficile infections in the baseline year of 2011 with 2013.

The HAI Progress Report describes significant reductions reported at the national level in 2013 for nearly all infections. Surgical-site infections showed a 19 percent reduction in 10 procedures tracked in the report between 2008 and 2013. Colorado’s progress in reducing these infections was on track or significantly better than the national standard, the CDC reports.

However, the report shows a 6 percent increase in catheter-associated urinary tract infections between 2009 and 2013, “signaling a strong need for additional prevention efforts,” the CDC said. Although, initial data from 2014 seem to indicate that these infections have started to decrease. Colorado’s infection rate was lower, or better, than the national standardized infection ratio.

More than 14,500 hospitals and other healthcare facilities provide data to CDC’s National Healthcare Safety Network for this report.

“Despite progress, the nation did not reach the 2013 goals,” the CDC says. “More action is needed at every level of public health and health care to improve patient safety and eliminate infections that commonly threaten hospital patients.”

Specialized endoscopes used to treat pancreatic cancer and other GI diseases likely spread the rare bacteria from patient to patient, even the hospital reportedly cleaned the equipment per manufacturers’ recommendations.

A sign placed out on the 16th Street Mall beckoned people in late March 2014 to sign up for health insurance through the Affordable Care and Connect for Health Colorado. (Kathryn Scott Osler, The Denver Post)

Brokers and agents in the field continue to report serious problems with online enrollment at Connect for Health Colorado, the state health insurance exchange established under the Affordable Care Act.

Connect for Health officials report they enrolled about 12,600 people in health and dental insurance Monday, Dec. 15 — “more than any single day ever before on the marketplace,” an exchange spokesman said.

“We recognize our systems were challenged at multiple points by a late rush,” exchange spokesman Luke Clarke said. “While we regret the inconvenience and justified frustration experienced by many customers and broker partners, the number of successful enrollments in new and renewed coverage far outnumber the difficulties.”

Connect for Health officials told The Denver Post they can’t readily track how many people are having problems with the enrollment system, yet some brokers dispute this.

The exchange issues tickets to callers when they can’t fix their problems on the spot. The “trouble tickets,” as brokers call them, start with the date and end with a sequence number, such as 141215-001234. Brokers assume the tickets are issued sequentially — in simple numerical order.

One broker received a a sequence number just under 9000 on Monday, Dec. 15, the deadline for enrolling for coverage effective Jan. 1. On preceding days, the numbers were running in the 3000-4000 range. Connect for Health officials say it is a wrong assumption that 3,000 to 4,000 enrollees were experiencing problems those days, in part because a person who calls more than once will generate multiple ticket numbers.

“Every call received is logged with an incident or tracking number,” Clarke said. “When we send an automated email response, they get numbers. And we may create multiple numbers for a single issue because the same person contacts us more than once.”

“That’s just for people who had the patience to wait on hold for most of an hour,” said ACA-certified broker Mike Eubanks, co-owner of Rosita Risk Management LLC in Colorado Springs.

The high volumes create longer waits, Clarke said.

Clarke said the exchange can quantify unresolved account problems by running a special report. “We don’t have the time to do that immediately while helping customers,” Clarke said.

“That said, we have received many reports of technical problems,” he said. “The majority have been forgotten passwords and locked accounts.”

Since Nov. 10, the technical problems officials have seen involve the financial application process for tax credits or Medicaid. The process has confused users into starting over and thus making multiple applications. Some users also are seeing a “500” (server) error message at some point in the process, Clarke said. And people have reported errors the exchange can’t duplicate in its own testing.

“We remain committed to completing January enrollments for anyone who initiated the process before Dec. 15 — whether they are working on their application alone or with assistance,” Clarke said in a statement Tuesday.

Eubanks, who said he also has been a website developer for a long time, doesn’t find the Connect for Health site even minimally user-friendly.

“We experienced lockups or crashes at more than 10 different points in their systems,” Eubanks said of the merged Connect for Health and Medicaid enrollment portal.

A sign placed out on the 16th Street Mall beckoned people in late March to sign up for health insurance through the Affordable Care and Connect for Health Colorado. (Kathryn Scott Osler, The Denver Post)

Consumer complaints are piling up over technical difficulties with renewing or enrolling in health insurance plans through the state exchange, Connect for Health Colorado.

The system seemed completely broken when Warren Kolber tried to enroll on Dec. 15, the deadline to enroll for coverage effective Jan. 1.

When he called the help line, Kolber said, he was automatically disconnected. When he tried the live chat feature on the exchange website, he was in the queue for hours, reached the front and then was disconnected.

There was a message: “Status: canceled. There are no agents available to chat with you right now. Please try again later.”

“My family is simple not able to purchase a plan through Connect for Health by the Dec. 15 deadline due to technical problems,” said Kolber, a 55-year Lone Tree man who’s worked in the health care industry for more than 20 years.

He said technical issues have plagued his family for months, since May when he tried to add and drop different family members.

“I finally gave up on 2014,” Kolber said.

But when he tried to enroll for 2015, despite countless calls and recent assurances from Connect for Health that everything would be fixed, he still couldn’t sign up.

Connect for Health’s response was its often-given assurance: The exchange will work with anyone who began the application process through Dec. 15 to get them coverage that is effective Jan. 1, spokesman Curtis Hubbard said. So far, officials have said, they have enrolled more than 25,000 people. About a third of them are new customers.

Yet many prospective insurance customers and their representatives are getting discouraged.

“It’s a convoluted mess,” said Tracy Speer, of Speer Insurance Services, an agent certified to assist with exchange enrollments. “Good luck just trying to report an income change. I was hoping this year the website would work better, it did not. I had to spend hours on hold with the exchange to get most policies issued.”

Mark Webb worked his way up from 199th in the live chat queue to first in line only to be told no agents were available to help him.

Webb, a Louisville resident, lost his job in July. So he got insurance through the exchange then, but when he heard Connect for Health officials encourage people to shop for lower rates in the highly changed 2015 market, he tried to do just that.

Colorado consumers looking to sign up during open enrollment under the Affordable Care Act enter the exchange for either private insurance or Medicaid through the same site. The system is supposed to then guide the client to the right pathway to coverage.
Webb was denied Medicaid, as he expected and wanted, but then he couldn’t seem to become eligible for private insurance or tax credits.

“I tried very diligently,” Webb said. “But I’ve never gotten all the way into the Connect for Health system.”

Electa Draper is the health writer for The Denver Post and has covered every news beat in a 22-year journalism career at three newspapers. She has a bachelor's degree in biology and a master's in journalism.